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Canavan, Blanche TOWN OF QUEENSBURY Pine Vteto Cemetery nntl Crematorium 21 Qtnker Road, Queenshnry, NY. 12804.5902 (518) 745.4476 (518) 745.4477 http ilw\v\v queensbury.net Funeral Director: -5- -R FPO iZ Name of Deceased: t V G H-F 1— CAW411A"1\1 Case Number: Date of Cremation: Retort: CV-k IPt'kJ'ICJ C L J Time Cremation Started: 'J Time Cremation Completed:Type of Container: 14 4-Rd woos Gw✓K,--f— 414-'4;kl Remarks: 9 115 _ 9 Ttr � 1 f� A -(� " Hoare o/ NntitrnI Benttf y ... A Good Plnie to Live ' DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements - please specify: If pulverization of cremate remains is requested, check here POLICIES, RULES AND REGULATIONS 1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-Friday. No Holidays or Sundays, arrangements can be made for Saturday. Pre-arrangements by telephone for acceptance of remains is necessary.* 2. Pine View .Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of Queensbury. 3. An authorization for cremation properly signed by the nearest next of kin or other authorized person stating that they do have the power and authority to arrange for the cremation of the , emains and to direct the disposition of the cremated remains, tr hat any personal possessions have either been removed or may be destroyed and agree to protect, defend and-save harmless Pine View Crematorium from any and all claims and demands for loss of damages which may be made against them by reason of or connected with the cremation of said remains and/or disposition of said remains as directed, whether such claims or demands are, or are not wholly groundless, false or fraudulent. This authorization in, addition to a regular burial permit must accompany the remains. 4. All remains must be encased in a casket or suitable alternate container. Caskets and containers must be of combustible material. No Styrofoam or plastic containers will be accepted. 5. The question relative to cardiac pacemakers must be answered on the authorization to 'cremate form before the remains will be accepted. 6. Unless other arrangements are made the cremated remains will l within to theled via funeralRhometered handling.thelservice. three Theredays willo cremation be bea$25.00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $300.00 Children (age 13 months to 12 years) $150.00 Infants (stillborn to 12 months) $100.00 * Additional $100.00 charge for cremations done after 3:00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $100.00 Any remains received after 3:30 P.M. Mon-Fri or Saturday will be charged an additional $100.00. TOWN OF QUEENSBURY PINE VIEW CEMETERY 8 CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone(518)Crematorium 745-4477(if no answer) Cemetery 7454476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject to its Rules and Regulations to cremate the remains of: i�I ANC k F, 4Et-C K (` ANAIJ AIA rnALF. (NAME) t , (SEX) D (STREET) (CITY) AT (ZIP CODE) who died on 3 day of AP R1 L 20©S at $7 (.F.OA 2 C o u 1 'a R"O i +r(PLACE) ( DRESS) Name and address of nearest Irving relative or name of person authorizing cremation: Q,c krnb�o C.At4k\[M . . Eeosaug�A' 11 9� 1 ego Relationship to deceased �u S(3Atv0 Name of Funeral Home IMPORTANT I represent that to the best of my knowledge,the deceased has has no cemaker in his or her body. (CIRCLE ONE) certify that I have the full power and authorization to arrange for the cremation of the remains and to direct the disposition of the cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and save harmless Pine View ,.Crematorium from any and all claims and demands for loss or damages which may be made against them by reason of or connected with the cremation of said remains as directed,whether such errands are re n wholly groundless,false or fraudulent. S) (ADDRESS) ( 1GNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS) Signed on this date: 4S�